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    <title>打印退费调查问卷</title>
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            <h4>退费、投诉原因调查表</h4>
            <p style="text-indent:2em;text-align:left">
                为完善我们的管理工作，帮助我们搞好服务服务质量，为更多的患者提供高质量、人性化的服务，请帮我们如实填写以下调查表，不甚感谢：
            </p>
            <p style="text-align:left">一．退费或投诉原因：</p>
            <p style="text-align:left">1. 医疗质量类：</p>
            <div style="text-align:left;">
                  <span th:text="${one.medicalQuality == 0 ? '√' : '&nbsp;&nbsp;&nbsp;'}"></span>
                  <p style="padding:0px;margin:0px;display: inline;">（1）医疗技术不好（包括治疗手法不熟练）</p>
            </div>
            <div style="text-align:left;">
                  <span th:text="${one.medicalQuality == 1 ? '√' : '&nbsp;&nbsp;&nbsp;'}"></span>
                  <p style="padding:0px;margin:0px;display: inline;">（2）疗效不满意</p>
            </div>
            <div style="text-align:left;">
                  <span th:text="${one.medicalQuality == 2 ? '√' : '&nbsp;&nbsp;&nbsp;'}"></span>
                  <p style="padding:0px;margin:0px;display: inline;">（3）医疗安全性没有充分告之</p>
            </div>
            <div style="text-align:left;">
                  <span th:text="${one.medicalQuality == 3 ? '√' : '&nbsp;&nbsp;&nbsp;'}"></span>
                  <p style="padding:0px;margin:0px;display: inline;">（4）夸大疗效</p>
            </div>
            <div style="text-align:left;">
                <span th:text="${one.medicalQuality == 4 ? '√' : '&nbsp;&nbsp;&nbsp;'}"></span>
                <p style="padding:0px;margin:0px;display: inline;">（5）沟通不客观或隐瞒</p>
            </div>
            <div style="text-align:left;">
                <span th:text="${one.medicalQuality == 5 ? '√' : '&nbsp;&nbsp;&nbsp;'}"></span>
                <p style="padding:0px;margin:0px;display: inline;">（6）其它：<u><span th:text="${one.medicalQuality == 5 ? one.supplement1 : ''}"></span></u></p>
            </div>
            <br/>
            <p style="text-align:left">2. 服务类投诉：</p>
            <div style="text-align:left;">
                <span th:text="${one.customerService == 0 ? '√' : '&nbsp;&nbsp;&nbsp;'}"></span>
                <p style="padding:0px;margin:0px;display: inline;">（1）服务态度（包括语言不友善，没有耐心）不好</p>
            </div>
            <div style="text-align:left;">
                <span th:text="${one.customerService == 1 ? '√' : '&nbsp;&nbsp;&nbsp;'}"></span>
                <p style="padding:0px;margin:0px;display: inline;">（2）服务质量（包括不及时回访，接待工作不好，接待工作不熟练等）不满意</p>
            </div>
            <div style="text-align:left;">
                <span th:text="${one.customerService == 2 ? '√' : '&nbsp;&nbsp;&nbsp;'}"></span>
                <p style="padding:0px;margin:0px;display: inline;">（3）医疗环境（包括卫生）不满意</p>
            </div>
            <div style="text-align:left;">
                <span th:text="${one.customerService == 3 ? '√' : '&nbsp;&nbsp;&nbsp;'}"></span>
                <p style="padding:0px;margin:0px;display: inline;">（4）推荐的项目设置不合理</p>
            </div>
            <div style="text-align:left;">
                <span th:text="${one.customerService == 4 ? '√' : '&nbsp;&nbsp;&nbsp;'}"></span>
                <p style="padding:0px;margin:0px;display: inline;">（5）服务流程不满意</p>
            </div>
            <div style="text-align:left;">
                <span th:text="${one.customerService == 5 ? '√' : '&nbsp;&nbsp;&nbsp;'}"></span>
                <p style="padding:0px;margin:0px;display: inline;">（6）注意事项告之不充分</p>
            </div>
            <div style="text-align:left;">
                <span th:text="${one.customerService == 6 ? '√' : '&nbsp;&nbsp;&nbsp;'}"></span>
                <p style="padding:0px;margin:0px;display: inline;">（7）对治疗没有信心</p>
            </div>
            <div style="text-align:left;">
                <span th:text="${one.customerService == 7 ? '√' : '&nbsp;&nbsp;&nbsp;'}"></span>
                <p style="padding:0px;margin:0px;display: inline;">（8）其它：<u><span th:text="${one.customerService == 7 ? one.supplement2 : ''}"></span></u></p>
            </div>
            <br/>
            <p style="text-align:left">3. 其他：</p>
            <div style="text-align:left;">
                <span th:text="${one.other == 0 ? '√' : '&nbsp;&nbsp;&nbsp;'}"></span>
                <p style="padding:0px;margin:0px;display: inline;">（1）因故无法坚持疗程</p>
            </div>
            <div style="text-align:left;">
                <span th:text="${one.other == 1 ? '√' : '&nbsp;&nbsp;&nbsp;'}"></span>
                <p style="padding:0px;margin:0px;display: inline;">（2）家人坚持终止治疗</p>
            </div>
            <div style="text-align:left;">
                <span th:text="${one.other == 2 ? '√' : '&nbsp;&nbsp;&nbsp;'}"></span>
                <p style="padding:0px;margin:0px;display: inline;">（3）其它：<u><span th:text="${one.other == 2 ? one.supplement3 : ''}"></span></u></p>
            </div>
            <p style="text-align:left">二．您的要求：</p>
            <div style="text-align:left;">
                <span th:text="${one.claim == 0 ? '√' : '&nbsp;&nbsp;&nbsp;'}"></span>
                <p style="padding:0px;margin:0px;display: inline;">（1）退费/退还未消费的费用</p>
            </div>
            <div style="text-align:left;">
                <span th:text="${one.claim == 1 ? '√' : '&nbsp;&nbsp;&nbsp;'}"></span>
                <p style="padding:0px;margin:0px;display: inline;">（2）更换管理员</p>
            </div>
            <div style="text-align:left;">
                <span th:text="${one.claim == 2 ? '√' : '&nbsp;&nbsp;&nbsp;'}"></span>
                <p style="padding:0px;margin:0px;display: inline;">（3）其它：<u><span th:text="${one.claim == 2 ? one.supplement4 : ''}"></span></u></p>
            </div>
            <br/>
            <p style="text-align:left">有其他进一步的投诉和说明，请直接拨打：025-58808706转黄伟经理</p>
            <p style="text-align:left">您的病历号：<label th:text="${ one.medicalNumber }"></label></p>
            <p style="text-align:left">接待人：<label th:text="${ one.createdBy }"></label></p>
            <p style="text-align:left">日期：<label th:text="${ one.creationTime }"></label></p>
            <p style="text-align:left">姓名（签字）:</p>
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